The risk of malignant progression among people with Barrett's esophagus is lower than has been seen in earlier studies, researchers reported.

Action Points

Explain that the risk of esophageal or gastric cardia adenocarcinoma or esophageal dysplasia in patients with Barrett's esophagus was lower than in previous studies, a large registry study from Ireland found.

Note that Barrett's esophagus was defined by pathology in this study and that patients with and without specialized intestinal metaplasia were included.

The risk of malignant progression among people with Barrett's esophagus is lower than has been seen in earlier studies, researchers reported.

In a large cohort of unselected patients with the condition, the rate of adenocarcinoma or high-grade dysplasia was 0.22% a year, according to Shivaram Bhat, MBBCh, MRCP, of Queens University Belfast in Northern Ireland, and colleagues.

On the other hand, it was markedly higher -- 0.38% a year -- using the stricter U.S. definition of Barrett's esophagus, Bhat and colleagues reported online in the Journal of the National Cancer Institute.

But both numbers are lower than seen in previous studies, which have reported a cancer incidence of between 0.58% and 3% per year among people with the condition, the researchers noted.

The wide variation has implications for the cost-effectiveness of cancer surveillance, they added.

To help clarify the issue, they turned to patients entered between 1993 and 2005 into the Northern Ireland Barrett's Esophagus Registry, one of the largest in the world of people with the condition.

Bhat and colleagues studied outcomes of 8,522 patients with the condition, defined as columnar lined epithelium of the esophagus with or without specialized intestinal metaplasia, until the end of 2008.

The British definition of the disease is simply columnar lined epithelium of the esophagus, but the U.S. definition requires the presence of specialized intestinal metaplasia, which is defined by the presence of goblet cells within the columnar mucosa, the researchers noted.

They were interested in three outcomes -- progression to adenocarcinoma of either the esophagus or gastric cardia or high-grade dysplasia of the esophagus.

Over an average follow-up of seven years, 79 patients were diagnosed with esophageal cancer, 16 with cancer of the gastric cardia, and 36 with high-grade dysplasia.

The combined incidence of the three conditions was 0.22% per year.

As to specifics of progression to cancer, they found:

Specialized intestinal metaplasia was found in 46% of the patients and among those the combined incidence of malignant progression was 0.38% per year.

Among those without specialized intestinal metaplasia at baseline, the incidence was 0.07% a year (HR 3.54, 95% CI 2.09 to 6.00, P<0.001).

Men were more likely to progress than women (HR 2.11, 95% CI 1.41 to 3.16, P<0.001).

Patients with low-grade dysplasia at baseline were also more likely to progress. The incidence was 1.40% a year versus 0.17% (HR 5.67, 95% CI 3.77 to 8.53, P<0.001).

The risk of progression did not appear to change markedly with time, Bhat and colleagues. The incidence in years one to six of follow-up was 0.25% per year, compared with 0.27% annually in years six to 11.

They noted that their study is one of the first to have such a large population of unselected patients, but they cautioned that it's based on registry data, so the definition of Barrett's esophagus may be less robust than it is at specialized centers.

On the other hand, they noted, the study probably reflects clinical practice and may have wider application than earlier studies.

They also cautioned that they lacked detailed data on endoscopic findings.

However, the study supports "many paradigms underlying current thoughts about the management of Barrett's esophagus," argued Douglas Corley, MD, PhD, of Kaiser Permanente in Oakland, Calif.

In an accompanying editorial, Corley argued that the study answers several important questions, including whether those with specialized intestinal metaplasia are at higher risk, whether the risk varies over time, and whether sex matters.

The lack of endoscopic data, though, may bias the results, he argued, since visual identification of abnormal esophageal lining is "a crucial requirement for diagnosing Barrett esophagus in most clinical studies."

But in this study, patients were identified only by the presence of columnar mucosa on an esophageal biopsy and it's "unclear how many patients actually had visible changes of Barrett esophagus on endoscopy."

The study was supported by the Ulster Cancer Foundation and the Health and Social Care Research and Development Office, Northern Ireland.

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.